CV: dr. Maiherizansyah SpPD

1. CV: dr. Maiherizansyah SpPD • Lahir: Tualang Cut,14 Mei1985 • Istri: Annisa Putri Yudhita, 1putri : Aysel Adreena Zansyah • Dokter Umum: FK UGM 5 Februari 2009 • SPPD : FK UGM 19 April 2016 Pekerjaan: • 2010-2011RSUD Calang Kab. Aceh Jaya • 2014-2015 RSUD Kab. Gorontalo Utara • 2015-2016 RSUDKab. Maluku Tenggara Barat • 2016-2017 RS Medicare Sorek Kab. Pelalawan • 2017-sekarang RSUD T Umar Kab. Aceh Jaya

2. Kaki Diabetes dr. Maiherizansyah SpPD

3. Kaki diabetes Kelainantungkai kaki bawahakibatkomplikasi kronis diabetes melitus yang tidakterkontrol. Kaki diabetes disebabkanoleh: * gangguanpembuluhdarah * gangguanpersarafan (neuropati) * infeksi

4. Keterlambatanpenanganan : • Tidaktahu • Takutamputasi • Kelalaian • Keterbatasansarana • Finansial • Under treatment

5. Gejalaneuropati • Neuropatisensorik perasaanbaalataukebal (parestesia), kurangberasa (parestesia) terutama di ujung kaki, pegal, nyeri • Neuropatimotorik Kelemahansistemotot, ototmengecil/deformitas, sulitmengaturkeseimbangantubuh, penonjolantulang caput metatarsal. • Neuropatiotonomik Kulit kaki kering, pecah, tidakadakeringat

6. Gejalagangguanpembuluhdarah • Sakit pada tungkai bila berdiri, berjalan, dan melakukan kegiatan fisik • Jika diraba kaki terasa dingin (tidak hangat) • Rasa nyeri kaki pada waktu istirahat dan malam hari • Sakit pada telapak kaki setelah berjalan • Jika luka – sukar sembuh • Tekanan nadi kaki kecil atau hilang • Perubahan warna kulit: pucat, kebiruan

7. Neuropati Perifer 80% lesi kaki diabetik Hilangnya sensasi protektif Hilangnya kewaspadaan akan trauma Ulserasi

8. Biomekanik Kaki Diabetes

9. 5 Cornerstones of diabetes foot care management 1. Identification of risk factors 5. Use appropriate footwear 2.Foot examination regularly 3. Education (patients, providers and family) 4.Treatment before Ulcer occurs

10. Risk Factors for diabetic foot ulceration n Intrinsic Factors • Peripheral Neuropathy • Micro-Macrovascular Diseases • Structural Deformity • Limited Joint Mobility • Nephropathy • Age • Duration of Diabetes • Visual Acuity • Previous Ulceration

11. Risk Factors for diabetic foot ulceration Extrinsic Factors • Minor mechanical trauma • Thermal Injury • Chemical Burns • Improper use of nail cutter • Smoking • Poor knowledge of diabetes • Psychological Factors • Alternative medication 1 2 Frykberg, Diabetic Microvascular Complications Today, May/June 2006

12. Pathway to diabetic foot ulceration Peripheral Neuropathy Minor Trauma Deformity Edema Peripheral Ischemia Callus Infections Components leading to foot ulceration Reiber GE, Vileikyte, Boyko EJ et al. Causal pathways for incident lower–extremity ulcers in patients with from two settings. Diabetes Care 1999: 157-162

13. Intrinsic FactorsPeripheral Neuropathy Autonomic Decreased Sweating Dry Skin Decreased Elasticity Fissure Ulcer

14. Intrinsic FactorsPeripheral Neuropathy Motoric Weakness Atrophy Deformity Abnormal Stress High Plantar Pressure Callus Formation

15. Intrinsic FactorsPeripheral Neuropathy Sensoric • Loss of protective sensation • Decreased pain threshold • Lack of temperature sensation and proprioception

16. Intrinsic FactorsPeripheral Arterial Disease (PAD) Risk Factors* PAD • Correlated with atherosclerosis • A1c >7%  26 % PAD • More aggressive • Narrowing vessel lumen -obstructive • Distal tissue necrosis • Hyperglycemia • Eleveted systolic BP • hyperlipidemia • Smoking • Cardiovascular disease * UKPDS

17. Clinical Classification of diabetic foot (Edmond)

18. 6 Steps for a complete Diabetes Foot Examination

19. Last 2 steps in the assessment ABI >1.2 0.9 – 1.2 <0.9 <0.6 Interpretation Rigid or calcified vessels or both Normal (or calcified) Ischemia Severe ischemia

20. Ankle-brachial index (ABI): • SBP in ankle (dorsalis pedis and posterior tibial arteries) • ___________________________________ • SBP in upper arm (brachial artery)

21. Resiko komplikasi kaki diabetik: • Amputasi • Cacat • Meninggal pencegahan

22. Apa yang harusdilakukan pasien?

23. Yang harusdilakukan 1. Periksa kaki setiaphari Apakahadakulitretak, melepuh, luka, perdarahan 2. Bersihkan kaki setiaphari padawaktumandidengan air bersihdansabun Keringkan kaki denganhandukbersih, lembut, yakinkankeringbenarterutamaselajari

24. Yang harusdilakukan 3. Pakai alas kaki (sandal atausepatu) untukmelindungi kaki, jugasaat di rumah 4. Gunakansepatuatau sandal yang baik sesuaiukuran kaki danenakdipakai. Syarat: * Ukuran– sepatulebihdalam panjang ½ inchilebihdarijari kaki * Bentuk– tidakruncing tinggitumitkurangdari 2 inchi * Bagiandalambawah (insole) tidakkasar, tidaklicin, terbuatdaribusakaret, plastikdengantebal 10-12 mm * Ruangdalamsepatulonggar

25. Yang harusdilakukan 5. Periksasepatusebelumdipakai: apakahadakerikil, bendatajam (duri, jarum). Lepassepatuselang 4-6 jam, gerakkanpergelangandanjari kaki agar sirkulasidarahbaik 6. Bilaadalukakecil, obatilukadantutupdenganpembalutbersih. Periksaapakahadatandaradang

26. Yang harusdilakukan 7. Segerakedokterbila kaki mengalamiluka 8. Periksakan kaki kedoktersecararutin

27. Apa yang tidakbolehdilakukan?

28. Yang tidakbolehdilakukan 1. Merendam kaki 2. Mempergunakanbotol airpanasatauperalatanlistrikuntukmemanaskan kaki 3. Jangangunakanbatu / siletuntukmenghilangkankapalan (callus)

29. Yang tidakbolehdilakukan 4. Merokok 5. Memakaisepatuataukaos kaki sempit 6. Menggunakanobat-obattanpaanjurandokteruntukmenghilangkan ‘mataikan’

30. Yang tidakbolehdilakukan 7. Menggunakansikatataupisauuntuk kaki 8. Membiarkanlukakecil di kaki, sekecilapapunlukaitu

31. Management • Wound control • Metabolic control • Microbiological control • Vascular control • Mechanical control • Educational control

32. Wound Control 1 Incision, drainage, debridement and necrotomy Management of infections in tissue and bone Exudate Management Keep control of proliferation phase and infections

33. Metabolic Control 2 • Hyperglycemia • Will inhibit process of wound recovery • Inhibit growth factor, collagen synthesis and fibroblast activities • 2. Hypoalbuminemi • 3. Hypertension • 4. Decrease of heart and kidney function • 5. Dyslipidemia • 6. Anemia • 7. Other diseases caused by diabetes

34. Infection Control 3 Need aggressive therapy Usually there are no symptoms or signs of infection External Infection: Positive gram bacteria Internal Infection: Negative gram bacteria

35. Gram positive

37. Gram negative

38. Vascular Control 4 Neuroischemic Foot Atherosclerosis can cause total block in the blood vessels Decrease of blood flow to the wound Critical Limb ischemia: Amputation Warning

39. Pharmacotherapy of Claudication Cilostazol (100 mg orally 2 times/d) is indicated as an effective therapy to improve symptoms and increase walking distance in patients with lower extremity PAD and intermittent claudication (in the absence of heart failure). ACC/AHA 2006 PAD Guidelines

40. Mechanic Control 5 • Principle: • Reduce stress on the wound • Off loading • Might be bed rest • Non-weight bearing • Use of walker, wheel-chair or crutches • Use special shoes (‘half-shoes’) • Distribute the body weight to all surfaces of the foot

41. Summary • 2 risk factors for diabetic foot: intrinsic and extrinsic. • Check feet regularly to prevent ulcers. • Diabetes foot care management: identification of risk factors, foot examination regularly, treatment before ulcer occurs, use appropriate foot wear, education. • Management of foot ulcers: wound control, metabolic control, infection control, vascular control, mechanic control.

42. Terimakasih